Cardiovascular Assessment - Health Assessment

**Importance of Cardiovascular Assessment** Cardiovascular disease (CVD) is the leading cause of death for men and women of most racial and ethnic groups in the United States (Centers for Disease Control and Prevention, 2023).​ One person dies every 33 seconds in the United States from CVD. That i...

**Importance of Cardiovascular Assessment** Cardiovascular disease (CVD) is the leading cause of death for men and women of most racial and ethnic groups in the United States (Centers for Disease Control and Prevention, 2023).​ One person dies every 33 seconds in the United States from CVD. That is 2,618 CVD-related deaths each day.​​ About 695,000 people in the United States die from heart disease yearly. That is one (1) in every five (5) deaths.​​ Heart disease cost the United States about \$239.9 billion annually from 2018 to 2019, including costs related to healthcare services, medicines, and lost productivity due to death.​ **Cardiovascular Health History Questions** The health history of the cardiovascular system includes the individual's medical history, lifestyle choices, and any knowledge deficits they may have about cardiovascular disease.​​ Data collected from the health history is used to determine the focus and depth of the physical assessment. Review the sample questions used by the nurse to obtain health history information related to cardiovascular disease. **Lifestyle and Cardiovascular Health** Lifestyle choices directly impact cardiovascular health. It is essential that risk factors are reviewed during the health history to better understand a client's chances of being diagnosed with a cardiovascular disorder.​ Risk factors include tobacco use, sedentary lifestyle, elevated cholesterol levels, unhealthy diet, and excessive alcohol use. Understanding that these can be modified by changing behavior is essential to teaching clients about cardiovascular disease prevention practices.​ Diet can have a significant impact on health. Sharifi-Rad et al. (2020) show in their analysis of studies that adding plant-food bioactive derivatives have a cardiovascular protective effect and should be considered as one change clients can make to reduce their risk. Plant-food bioactive derivatives include, but are not limited to:​ Polyphenols can be found in broccoli, carrots, spinach, and red lettuce​. Flavonoids can be found in bananas, pears, grapes, tomatoes, and wheat​. Carotenoids can be found in spinach, kale, corn, watermelon, and carrots​. Omega3 fatty acids can be found in flaxseed oil, canola oil, chia seeds, salmon, shellfish, and soybeans.​ Phytosterols can be found in almonds, walnuts, pistachios, cashews, and pecans. **Preparing to Assess the Cardiovascular System** The cardiovascular system includes the heart, great vessels, arteries, and veins.​ To prepare for the assessment, wash your hands and obtain and disinfect your stethoscope. You will also need a ruler that measures centimeters. Additional considerations include: A warm, quiet, and private environment is important for the client\'s comfort and accuracy of the assessment. Always place the stethoscope on the bare skin to avoid sound interference caused by room noise or the client's clothes. Remember that the base of the heart is in the upper chest; the apex is at the bottom. This is important to get the most accurate stethoscope placement. For example, the apical impulse should occupy only one interspace, the 4th or 5th, and be at or medial to the midclavicular line. Use the diaphragm of the stethoscope to pick up high-pitched sounds and the bell to hear lower-pitched sounds. Always listen over each area of the heart for one or more complete cardiac cycles (lub-dub).​​ A complete cardiac cycle is one heartbeat. The heart rate is the number of cardiac cycles, or heartbeats, in one minute.​ **Techniques for Assessing the Cardiovascular System** Heart assessment involves inspection, palpation, and auscultation. Nurses rarely use percussion to assess the size of the heart. Inspection: Look for abnormalities or visual pulsations. ​​ Palpation: Feel for abnormalities in surface structures or pulsations. Palpation is also used to identify the correct location for cardiac auscultation.​​ Auscultation: Use the diaphragm and bell of the stethoscope to assess the heart rate and rhythm, then listen over the precordium for the sounds created by the flow of blood through the valves. The precordium is the area of the anterior chest that overlays the heart and great vessels. When auscultating the heart, use the following landmarks:​ second intercostal space right of the sternal border​ second intercostal space left of the sternal border​ third intercostal space left of the sternal border ​ fifth intercostal space left of the sternal border​ fifth intercostal space at the left midclavicular line **Assessment of the Cardiovascular System** Perform the cardiovascular assessment as follows:​ Expose the torso from the waist to the shoulders. Be sure to keep the client covered when not assessing to reduce environmental exposure and maintain privacy.​​ Palpate then auscultate the carotid artery.​​ With the head of the bed elevated 40 degrees, inspect the jugular venous pulse.​​ Inspect, palpate, and auscultate the anterior chest.​​ Inspect the PMI, if visible, at the 4th to 5th intercostal space near the left midclavicular line.​​ Palpate the PMI with the client in supine and left lateral positions.​​ Using the palmar surface of your fingers, palpate the precordium for additional pulsations or abnormalities.​ Inspect, palpate, and auscultate each area before moving to the next. Remember that the purpose of inspection is to discover any visual abnormalities, such as bruising, wounds, bumps, masses, or visible pulsations. Sometimes, things are less visible because of the individual\'s body characteristics. For example, inspection of the point of maximum impulse (PMI) may not be visible in larger individuals. The purpose of palpation is to feel for structural abnormalities and assess pulsations. Palpation is also used to identify the correct location for auscultation of the cardiovascular system. Auscultation is used to listen for normal or abnormal valve closure and murmurs and bruits (turbulent blood flow through a narrowed area). **Locating Heart Sounds** During auscultation, listen carefully to the heart sounds to determine abnormal clicks or pops when the valves open and close. Listen during the cycle for extra sounds that are heard between systole and diastole, or diastole and systole. Be sure to listen over each landmark area with both the diaphragm and the bell of the stethoscope. ​ **A = Aortic Valve** Location: 2nd intercostal space at the right sternal border​ Sound best heard: Closing of aortic valve​ Blood flow: From left ventricle into aorta S2 louder than S1 **P = Pulmonic Valve** Location: 2nd intercostal space at the left sternal border​ Sound heard best: Closing of pulmonic valve​ Blood flow: From right ventricle into pulmonary artery S2 louder than S1 **E = Erb's Point** Location: 3rd intercostal space at the left sternal border​ Sound best heard: Closing of all valves​ Blood flow: Through all valves S2 = S1 **T = Tricuspid Valve** Location: 5th intercostal space at the left sternal border​ Sound best heard: Closing of tricuspid valve​ Blood flow: From right atrium to right ventricle S1 louder than S2 **M = Mitral Valve** Location: 5th intercostal space at the midclavicular line​ Sound best heard: Closing of mitral valve​ Blood flow: From left atrium to left ventricle S1 louder than S2 **Normal Heart Sounds** When you auscultate the heart sounds, you will use the bell and diaphragm of your stethoscope.​ Normal heart sounds have higher pitches and are heard best with the diaphragm.​ Heart sounds are created by the closure of the heart valves located between the chambers of the heart and are associated with the contraction and relaxation of the heart. These valves impact the flow of blood into and out of the chambers.​ As you auscultate over the precordium, you should hear \"lub-dub.\"​ The sounds are labeled as S1, which corresponds to the closure of the mitral and tricuspid valves and have the characteristic sound of \"lub.\"​ S2 corresponds to closures of the aortic and pulmonic valves, with the characteristic sound of \"dub.\" ​ Listen a second time using the bell to hear lower-pitched sounds, such as altered blood flow through malfunctioning heart valves (murmurs).​ Auscultate in a set pattern from top to bottom: Aortic, Pulmonic, Erb's, Tricuspid, and Mitral (APETM)​. **Understanding Heart Murmurs​** A common type of abnormal heart sound is a murmur, caused by turbulent blood flow through the cardiac valves. Heart murmurs can be functional due to an increase in blood flowing through a valve (caused by strenuous exercise or pregnancy) or pathologic (caused by dysfunction of one or more heart valves). ​ As a novice examiner, abnormal cardiac sounds, including murmurs, are often difficult to identify. To gain experience with all heart sounds, review the client's history and physical assessment completed by the healthcare provider to see if an abnormal heart sound has been identified in the client. If yes, record the details for reference when completing the nursing assessment. **Cardiovascular Risk Factors** Risk factors for cardiovascular disease fall into two categories: those that can be controlled by an individual (modifiable) and those that cannot (non-modifiable). The nurse applies this knowledge during the health assessment by asking about cardiovascular risk factors, helping the client determine which risk factors are present, and educating the person on positive changes they can make to improve their cardiovascular health. It is important for those completing a physical examination to help individuals understand that even though a risk factor may be considered non-modifiable, it is possible to decrease their risk of illness by controlling modifiable risk factors.​ **Risk Factors** **Psychosocial​** Stress: Increases epinephrine and cortisol levels, which can lead to chronic hypertension and damage to the arterial walls, causing injury and accumulation of atherosclerotic plaques.​ Contraceptive Use: Increases fluid retention leading to hypertension and increases blood clotting, a primary cause of myocardial infarction, stroke, pulmonary emboli, and deep vein thrombosis (DVT).​ Occupation: Sedentary jobs that require extended periods of inactivity and cause weight gain, reduced exercise tolerance, and a higher risk of cardiovascular disease. If the worker is exposed to pollution or toxins, this can also increase the cardiovascular risk.​ Smoking: Causes injury to the endothelium (inner lining) of arteries and increased clotting, leading to accumulation of atherosclerotic plaques, and increased risk of cardiovascular events.​ **Social Determinants of Health​​** Cardiovascular disease is the leading cause of death in high-income countries and is projected to increase worldwide (Powel-Wiley et al., 2022). While current research has identified, modified, and treated individual-level risk factors, significant inequalities continue to persist over time. Although changing at different rates worldwide, the increase of risk factors has increased research efforts on the causes of the risk factors (i.e., the "causes" of the causes), which include the social determinants of health. The social determinants of health reflect the impact of the social environment on health among people sharing a particular community. Imbalances in social determinants of health have been attributed to the inequities in health observed between and within countries. These inequities lead to higher rates of morbidity and mortality from cardiovascular events among populations with poor social determinants of health. **Developmental Considerations** Many changes that occur in the cardiovascular system are directly related to normal developmental changes in the body over a lifetime.​ The heart rate of a newborn is fast, 100--180 bpm. As the child grows, the heart rate slows to the 70--100 bpm rate of an adult.​ Older adults experience decreases in cardiac function and efficiency.​ The overall size of the heart decreases.​ Contractility of the cardiac muscles lessens.​ Thickening of the heart valves impedes function.​ Blood vessels lose elasticity.​ Over the course of a lifetime, lifestyle choices---including dietary habits, physical activity, weight management, and tobacco use---contribute to pathophysiologic changes that negatively impact health. Unfortunately, these changes within the body begin at a young age. Although children and teens usually do not show symptoms of heart disease, the silent buildup of plaque (fatty deposits) that starts in childhood can have a serious impact on their health later in life.​ Understanding the impact of both normal development and lifestyle influences on the body provides nurses with the knowledge to understand physical assessment cues, the pathophysiological changes they represent, and plan interventions and teaching to promote the health of those in their care.​ **Infants** Blood pressure is not regularly done in children less than three years of age. Use skin color and alertness as key indicators of adequate vascular function. If blood pressure is required prior to 3 years, the nurse will use a blood pressure cuff and doppler flow meter. The blood pressure in the thigh and arm should be essentially the same for infants less than 12 months of age. At the age of 12 months, the systolic blood pressure will be 10--40 mmHg higher in the thigh than in the arm. Differences in blood pressure between the arm and thigh in children 18 months or older could indicate coarctation of the aorta. Dramatically enlarged lymph nodes in infants and children generally indicate infection. **Pregnant Women** First trimester: Assess for a history of hypertension and establish a norm for blood pressure range. Second trimester: Blood pressure may be lower due to dilation of the peripheral blood vessels. Third trimester: Blood pressure should return to normal prepregnancy levels. However, blood pressure may increase dramatically during this trimester as the blood volume is almost doubled. Monitor closely for pregnancy-induced hypertension or preeclampsia. Pressure from the enlarging uterus can cause venous stasis, resulting in varicose veins, hemorrhoids, and peripheral pitting edema. **Older Adults** The cardiovascular system undergoes several changes as a person ages, impacting its structure, function, and efficiency. Some of the critical impacts of aging on the cardiovascular system include:​ Arterial stiffness increases blood pressure and cardiac workload​. Atherosclerosis leads to narrowed arteries, reduced blood flow to vital organs, and increased risk of cardiovascular events (e.g., angina, myocardial infarction, stroke).​ Cardiac structure and function changes include ventricular hypertrophy (thickening), decreased compliance of atria and ventricles, and abnormal cardiac conduction (dysrhythmias). Each of these changes may contribute to decreased cardiac output.​ Decreased heart rate variability, which is, essentially, a difference in the length of time that occurs between heartbeats, is associated with an increased risk of cardiovascular disease and mortality.​ Increased risk of dysrhythmias is also associated with aging, including atrial fibrillation, ventricular tachycardia, and bradycardia. ​ Impaired baroreceptor function leads to difficulty regulating blood pressure and orthostatic hypotension. The baroreceptors sense changes in arterial pressure and signal the cardiovascular system to adjust blood pressure. **Genetic Role in Cardiovascular Disease​** Some people have a common genetic disorder called familial hypercholesterolemia (FH). People with FH have increased levels of LDL cholesterol, which makes them more likely to develop heart disease at a younger age and increases their risk of dying from the disease. For many people with FH, diet and exercise alone are not enough to control their cholesterol levels, and they require medications to maintain a normal LDL cholesterol level.​ After a diagnosis of FH, people may worry about the impact the disease will have on their lives and fear premature death. Partnering with healthcare providers to manage increased cholesterol using medication, diet, and exercise contributes to heart health.​ Finding out that a person has FH not only helps that person but can help their entire family. Other members of the family can be tested for FH, and those with the disorder can take steps to lower their chances of developing and dying from heart disease. ​